7 ms·

With California and New York both exploring statewide single payer healthcare it looks like the Overton window is moving closer to legitimate discussion of a na

With California and New York both exploring statewide single payer healthcare it looks like the Overton window is moving closer to legitimate discussion of a nationwide single payer plan in the US. It’ll be interesting to watch, since this is such a hot-button topic here on many levels.

vmception 4y ago
as long as these plans can negotiate and also use their market power to reduce the prices that healthcare services charge to Americans, but starting within their jurisidction a significant portion of the consensus failings have been because simply having insurance for all is just a bandaid, and this has been an accurate criticism of one party's tax and spend trend whether that seems like a conversation derailing political statement or not
lotsofpulp 4y ago
It is dead in the water. The Republicans show no sign of supporting broad non means tested or non age gated taxpayer funded healthcare, and they hold the cards in the US Senate. On the state level, any broad based benefit that does not discriminate is also futile because benefit recipients can move into the state and payers for the benefits can move out of the state. See Vermont for the previous trial of this: https://en.wikipedia.org/wiki/Vermont_health_care_reform https://en.wikipedia.org/wiki/Vermont_health_care_reform It the same problem with homelessness, education, and mental healthcare (a subset of healthcare). Without a border to limit the ratio of net benefit recipients to net payers, the numbers will not work out.
- irrational 4y ago
  You really think people are going to flee NYC and the large cities in CA over this?
  - gleenn 4y ago
    Anecdata but I personally know more than a few people who moved to Nevada to avoid California taxes, so yes.
    - colinmhayes 4y ago
      And I personally know more than a few people who have moved from flyover states to California. Goes both ways.
      - lotsofpulp 4y ago
        The relevant question would be the ratio of the movement of net payers to net benefit recipients into the system.
  - mywittyname 4y ago
    OP sounds to be arguing the opposite. One lives in a low tax state while earning money / paying taxes, then retires to a rural part of NY / CA to receive tax-payer-backed benefits without paying for them.
    - pkaye 4y ago
      Retirees usually use Medicare.
    - exhilaration 4y ago
      Having a bunch of (medicare-covered) retirees (with no school-age kids) spending their (taxable) social security income in NY / CA sounds pretty great. Much better than losing them to Florida or Arizona. Bonus if the states get to tax their estates in the end.
      - deleted 4y ago
        [deleted]
      - lotsofpulp 4y ago
        The fact that they are Medicare covered means the retirees will choose to retire in lower tax jurisdictions. They do not need state governments to provide healthcare.
      - mynameishere 4y ago
        I think he means people who have enough money at, say, 40 years old, to pay for everything but health insurance. I can see the temptation myself, since insurance as you get into your 50s can be 2000/month or more. If NY State pays that while I wait for Medicare to kick in, hey, FIRE!
      - ceeplusplus 4y ago
        Half of California's tax revenue comes from the top 1% [1]. Medicare retirees are almost guaranteed to not be part of that 1%. You're talking huge tax revenue losses here if the 1% do decide to leave. [1] https://lao.ca.gov/LAOEconTax/Article/Detail/7 https://lao.ca.gov/LAOEconTax/Article/Detail/7
- toomuchtodo 4y ago
  California is the fifth largest economy in the world. New York State's GDP is roughly $1.5 trillion, 8 percent of the U.S. total. They are resourced at levels of entire OECD countries that offer universal healthcare. If Congress can't get its shit together, states that can should. https://www.politifact.com/factchecks/2015/sep/01/dan-gecker/dan-gecker-says-us-only-wealth-nation-without-univ/ https://www.politifact.com/factchecks/2015/sep/01/dan-gecker... https://web.archive.org/web/20160107120644/https://www.who.int/bulletin/volumes/92/12/14-141762.pdf https://web.archive.org/web/20160107120644/https://www.who.i...
  - newaccount2021 4y ago
  - lotsofpulp 4y ago
    30% of the US federal budget is healthcare spending. https://www.usaspending.gov/explorer/budget_function https://www.usaspending.gov/explorer/budget_function And that is only because a ton of people do not actually get healthcare, either because deductibles dissuade them or they do not pass the means testing to get enough subsidies to buy Medicaid or healthcare.gov insurance. And that is because Medicaid severely underpays doctors to the point that if you visit a US city subreddit, one of the frequently asked topics is "where can I find a doctor that will accept Medicaid". I think this issue can be too big for even NY or CA. It seems like it is for the US federal even, such that the political will only exists to provide healthcare via extreme price segmentation/discrimination. But most importantly, you can surely have your high risk pregnancies and hemophiliacs and cancer or whatever other high cost patient population move to the state, and the price tags on those patients is nothing to sneeze at.
    - toomuchtodo 4y ago
      Very broad strokes, doctors in the US are overpaid and conservatives legislated Medicare can't negotiate drug prices. Lots of room to drive down costs. Spending is high because of a dysfunctional system driven by profit instead of care. https://www.npr.org/sections/money/2019/03/12/702500408/are-doctors-overpaid https://www.npr.org/sections/money/2019/03/12/702500408/are-... https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.0204 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.... https://www.bostonglobe.com/2021/10/25/opinion/let-medicare-negotiate-lower-drug-prices/ https://www.bostonglobe.com/2021/10/25/opinion/let-medicare-... https://www.brookings.edu/research/a-dozen-facts-about-the-economics-of-the-u-s-health-care-system/ https://www.brookings.edu/research/a-dozen-facts-about-the-e... https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019 https://www.commonwealthfund.org/publications/issue-briefs/2...
rootusrootus 4y ago
Something is going to have to change. As it stands, there isn't a plan on the national insurance exchange that I can buy that's even remotely as cheap as my company's plan (actual premium, not just the fraction paid for by employee).
- lettergram 4y ago
  Probably because your company can negotiate and control the population characteristics (unlike the exchange). Or is self-insured, meaning they aren’t profit motivated. Insurance on average is always more expensive than not having insurance on average. The question is given that risk, how much of a premium can / will insurance companies take. Turns out they like high profits and low risk.
  - akomtu 4y ago
    Are health insurance companies allowed to discriminate customers by their health status, that includes age? With a good deal of populace morbidly obese and not even bothering to exercise, it's expected that healthy 25 yo are going to pay crazy insurance payments. Corps, on the other hand, absolutely do discriminate by all sorts of characteristics and insurers know what they are signing up for. Offer health insurance tiers by age and BMI and watch premiums getting reasonable again (for some).
    - lotsofpulp 4y ago
      No. Per the Affordable Care Act, since 2010 health insurance companies can only price insurance based on age, smoking status, and location. And they must offer insurance to all. https://www.healthcare.gov/how-plans-set-your-premiums/ https://www.healthcare.gov/how-plans-set-your-premiums/
    - DaveExeter 4y ago
      > Offer health insurance tiers by age and BMI and watch premiums getting reasonable again That's not the way health insurance works. The way it works it that the young and healthy are overcharged and that overcharge is given to the old and unhealthy.
ars 4y ago
Massachusetts may try it as well: https://masscare.org/ https://masscare.org/ It'll be a very interesting experiment, if it works, other states will copy it. If it fails wealthy people will leave those states for places with lower taxes, and poorer people will move in to gain free health care. There's a reason the most populous states (CA, NY, MA) are the ones trying it first, and it's not because it's cheaper.
- lotsofpulp 4y ago
  Vermont tried it first, and it is tiny, and stopped it because it was unaffordable. I would say the correlation is with how Democrat a state is, not how populous it is. And while it is good for political campaign slogans, I highly doubt CA/NY/MA legislators actually vote it into law.
- airstrike 4y ago
  I can't help but read "massacre" when I see "masscare"... As they say, naming things is harder than you'd think
- TMWNN 4y ago
  >Massachusetts may try it as well: https://masscare.org/ https://masscare.org/ Massachusetts has had 98% health care coverage for more than 15 years. (The only countries in the world with more than that are those, such as the UK, in which no membership card is needed for receiving care.)
  - lotsofpulp 4y ago
    Health care coverage with a deductible and copays is not at all similar to taxpayer funded healthcare such as that in the UK.
    - TMWNN 4y ago
      That has nothing to do with my point, which is that Massachusetts has 98% coverage. Neither the UK's monolithic NHS that combines single-payer insurance and (more or less) 100% free on delivery with no membership card, nor Canada's single-payer insurance with no legal private alternative, is the norm internationally. Germany, Austria, Switzerland, and the Netherlands all have Obamacare-like systems with dozens of competing private insurance plans with premiums. 30% copay is the norm in France's three separate government insurance plans. Australia has single-payer insurance but people are heavily incentivized to move to private plans. Etc., etc.
lettergram 4y ago
Why would you want it nation wide? Even if you “support it”, I’d much rather watch the implications from the various experiments across states. Then we can select the best option. Personally, I’d like to see some states ban healthcare outright. Others have full coverage and everything in between. Then wait 10 years and we can see the results. I strongly suspect there would be states willing to do this.
- tenpies 4y ago
  Exactly. US salaries for healthcare are the best on the planet, period. The comparison (and to be fair, this is a very high level) paints an extremely clear picture: United States $313,000 Germany $163,000 United Kingdom $138,000 France $108,000 Per: https://www.worldatlas.com/articles/countries-with-highest-paid-doctors.html https://www.worldatlas.com/articles/countries-with-highest-p... So yes, I absolutely want to see how many physicians stick around if you tell them "your salary will now be half and we're maxing our your workload". Alternatively, I want to see how long the State's finances last if they say "we'll pay the national market rate for your services and we're now maxing our your workload". And even then I don't want 10 years, I want a generation or two. Even pre-COVID we had multiple surveys indicating that 60-70% of doctors would not recommend becoming a doctor. I want to see how that number changes as States run their experiments.
  - throwaway2214 4y ago
    > "your salary will now be half and we're maxing our your workload" should be fine if they pay their student loans no? isnt that the main reason the salaries are so high? cost of living + debt
    - rhexs 4y ago
      Paying off 200K in debt with a 300K minimum salary is pretty trivial unless you immediately qualify for a 4 million dollar mortgage, buy a BMW, then get divorced six times after med school.
    - TuringNYC 4y ago
deleted 4y ago
[deleted]
Workaccount2 4y ago
I wonder if we could get an interstate cluster healthcare plan. NY, MA, CT, NJ joined together (ok RI, you too) certainly have the economic firepower and population numbers to get a good system going.
deleted 4y ago
[deleted]
DesiLurker 4y ago
its would be interesting to see a deep-blue state coalition single payer system. that might pave the way to a national version of it.
tootie 4y ago
Not to sounds hyperbolic, but we're moving farther and farther towards partitioning the country than we are towards M4A. The SC has just crossed the biggest line between liberals and conservatives for the last 50 years and signalled they're not done. The composition of the Senate and electoral college could put us a good 30+ years from being able to restore those rights. Best case scenario is both sides of the aisle double down on states' rights so liberals can have free choice and socialized medicine while the others can wait for maternal mortality rates to force their hands in a generation or two.

vmception 4y ago

as long as these plans can negotiate and also use their market power to reduce the prices that healthcare services charge to Americans, but starting within their jurisidction a significant portion of the consensus failings have been because simply having insurance for all is just a bandaid, and this has been an accurate criticism of one party's tax and spend trend whether that seems like a conversation derailing political statement or not

lotsofpulp 4y ago

It is dead in the water. The Republicans show no sign of supporting broad non means tested or non age gated taxpayer funded healthcare, and they hold the cards in the US Senate. On the state level, any broad based benefit that does not discriminate is also futile because benefit recipients can move into the state and payers for the benefits can move out of the state. See Vermont for the previous trial of this: https://en.wikipedia.org/wiki/Vermont_health_care_reform https://en.wikipedia.org/wiki/Vermont_health_care_reform It the same problem with homelessness, education, and mental healthcare (a subset of healthcare). Without a border to limit the ratio of net benefit recipients to net payers, the numbers will not work out.

irrational 4y ago
You really think people are going to flee NYC and the large cities in CA over this?
- gleenn 4y ago
  Anecdata but I personally know more than a few people who moved to Nevada to avoid California taxes, so yes.
  - colinmhayes 4y ago
    And I personally know more than a few people who have moved from flyover states to California. Goes both ways.
    - lotsofpulp 4y ago
      The relevant question would be the ratio of the movement of net payers to net benefit recipients into the system.
- mywittyname 4y ago
  OP sounds to be arguing the opposite. One lives in a low tax state while earning money / paying taxes, then retires to a rural part of NY / CA to receive tax-payer-backed benefits without paying for them.
  - pkaye 4y ago
    Retirees usually use Medicare.
  - exhilaration 4y ago
    Having a bunch of (medicare-covered) retirees (with no school-age kids) spending their (taxable) social security income in NY / CA sounds pretty great. Much better than losing them to Florida or Arizona. Bonus if the states get to tax their estates in the end.
    - deleted 4y ago
      [deleted]
    - lotsofpulp 4y ago
      The fact that they are Medicare covered means the retirees will choose to retire in lower tax jurisdictions. They do not need state governments to provide healthcare.
    - mynameishere 4y ago
      I think he means people who have enough money at, say, 40 years old, to pay for everything but health insurance. I can see the temptation myself, since insurance as you get into your 50s can be 2000/month or more. If NY State pays that while I wait for Medicare to kick in, hey, FIRE!
    - ceeplusplus 4y ago
      Half of California's tax revenue comes from the top 1% [1]. Medicare retirees are almost guaranteed to not be part of that 1%. You're talking huge tax revenue losses here if the 1% do decide to leave. [1] https://lao.ca.gov/LAOEconTax/Article/Detail/7 https://lao.ca.gov/LAOEconTax/Article/Detail/7
toomuchtodo 4y ago
California is the fifth largest economy in the world. New York State's GDP is roughly $1.5 trillion, 8 percent of the U.S. total. They are resourced at levels of entire OECD countries that offer universal healthcare. If Congress can't get its shit together, states that can should. https://www.politifact.com/factchecks/2015/sep/01/dan-gecker/dan-gecker-says-us-only-wealth-nation-without-univ/ https://www.politifact.com/factchecks/2015/sep/01/dan-gecker... https://web.archive.org/web/20160107120644/https://www.who.int/bulletin/volumes/92/12/14-141762.pdf https://web.archive.org/web/20160107120644/https://www.who.i...
- newaccount2021 4y ago
- lotsofpulp 4y ago
  30% of the US federal budget is healthcare spending. https://www.usaspending.gov/explorer/budget_function https://www.usaspending.gov/explorer/budget_function And that is only because a ton of people do not actually get healthcare, either because deductibles dissuade them or they do not pass the means testing to get enough subsidies to buy Medicaid or healthcare.gov insurance. And that is because Medicaid severely underpays doctors to the point that if you visit a US city subreddit, one of the frequently asked topics is "where can I find a doctor that will accept Medicaid". I think this issue can be too big for even NY or CA. It seems like it is for the US federal even, such that the political will only exists to provide healthcare via extreme price segmentation/discrimination. But most importantly, you can surely have your high risk pregnancies and hemophiliacs and cancer or whatever other high cost patient population move to the state, and the price tags on those patients is nothing to sneeze at.
  - toomuchtodo 4y ago
    Very broad strokes, doctors in the US are overpaid and conservatives legislated Medicare can't negotiate drug prices. Lots of room to drive down costs. Spending is high because of a dysfunctional system driven by profit instead of care. https://www.npr.org/sections/money/2019/03/12/702500408/are-doctors-overpaid https://www.npr.org/sections/money/2019/03/12/702500408/are-... https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.0204 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.... https://www.bostonglobe.com/2021/10/25/opinion/let-medicare-negotiate-lower-drug-prices/ https://www.bostonglobe.com/2021/10/25/opinion/let-medicare-... https://www.brookings.edu/research/a-dozen-facts-about-the-economics-of-the-u-s-health-care-system/ https://www.brookings.edu/research/a-dozen-facts-about-the-e... https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019 https://www.commonwealthfund.org/publications/issue-briefs/2...

rootusrootus 4y ago

Something is going to have to change. As it stands, there isn't a plan on the national insurance exchange that I can buy that's even remotely as cheap as my company's plan (actual premium, not just the fraction paid for by employee).

lettergram 4y ago
Probably because your company can negotiate and control the population characteristics (unlike the exchange). Or is self-insured, meaning they aren’t profit motivated. Insurance on average is always more expensive than not having insurance on average. The question is given that risk, how much of a premium can / will insurance companies take. Turns out they like high profits and low risk.
- akomtu 4y ago
  Are health insurance companies allowed to discriminate customers by their health status, that includes age? With a good deal of populace morbidly obese and not even bothering to exercise, it's expected that healthy 25 yo are going to pay crazy insurance payments. Corps, on the other hand, absolutely do discriminate by all sorts of characteristics and insurers know what they are signing up for. Offer health insurance tiers by age and BMI and watch premiums getting reasonable again (for some).
  - lotsofpulp 4y ago
    No. Per the Affordable Care Act, since 2010 health insurance companies can only price insurance based on age, smoking status, and location. And they must offer insurance to all. https://www.healthcare.gov/how-plans-set-your-premiums/ https://www.healthcare.gov/how-plans-set-your-premiums/
  - DaveExeter 4y ago
    > Offer health insurance tiers by age and BMI and watch premiums getting reasonable again That's not the way health insurance works. The way it works it that the young and healthy are overcharged and that overcharge is given to the old and unhealthy.

ars 4y ago

Massachusetts may try it as well: https://masscare.org/ https://masscare.org/ It'll be a very interesting experiment, if it works, other states will copy it. If it fails wealthy people will leave those states for places with lower taxes, and poorer people will move in to gain free health care. There's a reason the most populous states (CA, NY, MA) are the ones trying it first, and it's not because it's cheaper.

lotsofpulp 4y ago
Vermont tried it first, and it is tiny, and stopped it because it was unaffordable. I would say the correlation is with how Democrat a state is, not how populous it is. And while it is good for political campaign slogans, I highly doubt CA/NY/MA legislators actually vote it into law.
airstrike 4y ago
I can't help but read "massacre" when I see "masscare"... As they say, naming things is harder than you'd think
TMWNN 4y ago
>Massachusetts may try it as well: https://masscare.org/ https://masscare.org/ Massachusetts has had 98% health care coverage for more than 15 years. (The only countries in the world with more than that are those, such as the UK, in which no membership card is needed for receiving care.)
- lotsofpulp 4y ago
  Health care coverage with a deductible and copays is not at all similar to taxpayer funded healthcare such as that in the UK.
  - TMWNN 4y ago
    That has nothing to do with my point, which is that Massachusetts has 98% coverage. Neither the UK's monolithic NHS that combines single-payer insurance and (more or less) 100% free on delivery with no membership card, nor Canada's single-payer insurance with no legal private alternative, is the norm internationally. Germany, Austria, Switzerland, and the Netherlands all have Obamacare-like systems with dozens of competing private insurance plans with premiums. 30% copay is the norm in France's three separate government insurance plans. Australia has single-payer insurance but people are heavily incentivized to move to private plans. Etc., etc.

lettergram 4y ago

Why would you want it nation wide? Even if you “support it”, I’d much rather watch the implications from the various experiments across states. Then we can select the best option. Personally, I’d like to see some states ban healthcare outright. Others have full coverage and everything in between. Then wait 10 years and we can see the results. I strongly suspect there would be states willing to do this.

tenpies 4y ago
Exactly. US salaries for healthcare are the best on the planet, period. The comparison (and to be fair, this is a very high level) paints an extremely clear picture: United States $313,000 Germany $163,000 United Kingdom $138,000 France $108,000 Per: https://www.worldatlas.com/articles/countries-with-highest-paid-doctors.html https://www.worldatlas.com/articles/countries-with-highest-p... So yes, I absolutely want to see how many physicians stick around if you tell them "your salary will now be half and we're maxing our your workload". Alternatively, I want to see how long the State's finances last if they say "we'll pay the national market rate for your services and we're now maxing our your workload". And even then I don't want 10 years, I want a generation or two. Even pre-COVID we had multiple surveys indicating that 60-70% of doctors would not recommend becoming a doctor. I want to see how that number changes as States run their experiments.
- throwaway2214 4y ago
  > "your salary will now be half and we're maxing our your workload" should be fine if they pay their student loans no? isnt that the main reason the salaries are so high? cost of living + debt
  - rhexs 4y ago
    Paying off 200K in debt with a 300K minimum salary is pretty trivial unless you immediately qualify for a 4 million dollar mortgage, buy a BMW, then get divorced six times after med school.
  - TuringNYC 4y ago

deleted 4y ago

[deleted]

Workaccount2 4y ago

I wonder if we could get an interstate cluster healthcare plan. NY, MA, CT, NJ joined together (ok RI, you too) certainly have the economic firepower and population numbers to get a good system going.

deleted 4y ago

[deleted]

DesiLurker 4y ago

its would be interesting to see a deep-blue state coalition single payer system. that might pave the way to a national version of it.

tootie 4y ago

Not to sounds hyperbolic, but we're moving farther and farther towards partitioning the country than we are towards M4A. The SC has just crossed the biggest line between liberals and conservatives for the last 50 years and signalled they're not done. The composition of the Senate and electoral college could put us a good 30+ years from being able to restore those rights. Best case scenario is both sides of the aisle double down on states' rights so liberals can have free choice and socialized medicine while the others can wait for maternal mortality rates to force their hands in a generation or two.